Provider Demographics
NPI:1124613690
Name:TRUSTY, CANDY LEE
Entity type:Individual
Prefix:
First Name:CANDY
Middle Name:LEE
Last Name:TRUSTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 SAND CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-9374
Mailing Address - Country:US
Mailing Address - Phone:219-921-6237
Mailing Address - Fax:
Practice Address - Street 1:3134 E 79TH AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5738
Practice Address - Country:US
Practice Address - Phone:219-947-3789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015714A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist